Should Antiplatelet Therapy Be Held Perioperatively? The First Study Examining Outcomes in Patients Receiving Dual Antiplatelet Therapy in the Lower Extremity Free Flap Population

BACKGROUND: Antiplatelet agents are typically held in the perioperative period due to intraoperative bleeding concerns. Dual antiplatelet therapy regimens, such as aspirin and clopidogrel, have significant morbidity and mortality benefit in patients with a history of ischemic heart disease or peripheral vascular disease making these therapeutic regimens commonly encountered in patients with chronic wounds requiring free tissue transfer (FTT). Emerging evidence suggests holding platelet antagonists for surgical therapy may lead to high thrombotic risks such as perioperative myocardial infarction. Furthermore, our institution has found favorable outcomes in patients on dual therapy receiving skin grafts.1 The objective of our study is to evaluate the impact of aspirin and platelet antagonist on FTT outcomes and need of the transfusion in the setting of copious hemostasis. METHODS: A retrospective review of lower extremity FTT at our institution from 2011 to 2019 was performed. Data collected included demographics, comorbidities, administration of antiplatelet agents, and FTT characteristics. Outcomes of interest were blood transfusion volume, postoperative hematoma, and flap success. RESULTS: We identified 196 LE FTT procedures performed for lower extremity salvage in the chronic wound population. Median age at time of FTT was 57 years (interquartile range, 47–65). Median Charlson Comorbidity Index was 3.0 (interquartile range, 1.0–5.0). Comorbidities included diabetes 44.4%, peripheral vascular disease 20.4%. Thirty-five of these patients (17.9%) were taking dual antiplatelet therapy (aspirin and clopidogrel). Of these 35, clopidogrel was continued throughout the operative course in 14 patients (40.0%) while it was held on the day of surgery in 21 patients (60.0%). Comparisons were made between the dual antiplatelet group (DA, n = 35) and nonantiplatelet group (NDA, n = 161); the dual antiplatelet group was further analyzed by continued therapy (CT, n = 14) versus held therapy (HT, n = 21). The volume of intraoperatively transfused blood products was significantly higher for the DA versus NDA groups. Median Charlson Comorbidity Index was significantly higher in the CT versus HT groups (5.0 versus 3.0; P < 0.001). There was no significant difference in intraoperative transfusion volume for the CT (median, 438 ml) versus HT (median, 600 ml; P = 0.427) groups. Intraoperative thrombosis occurred in 2.5% of all FTT patients (n = 5/196). While the incidence was highest in the HT cohort (n = 2/21, 19.0%), it was not statistically significant. Incidence of postoperative hematoma (NDA: 7.5%, DA: 17.1%; P = 0.100) and flap success (NDA: 95.0%, DA: 91.4%; P = 0.418) was similar between the 2 groups. One patient in the HT group had a myocardial infarct on postoperative day 1. CONCLUSIONS: Despite increases in the volume of blood products transfused, FTT can be performed safely and successfully with perioperative administration of dual antiplatelet therapy. Antiplatelet therapy can be given throughout the operative course; holding antiplatelet therapy may result in cardiovascular risk. Holding clopidogrel on the day of FTT was not associated with decreased intraoperative transfusion. A multidisciplinary approach to surgical bleeding versus thrombotic risk is necessary in this comorbid population. REFERENCE: 1. Walters E, Naz I, Mehra S, et al. Chronic antiplatelet or anticoagulant therapy does not increase graft failure after split thickness skin grafting. J Vasc Surg. 2018;67:E213.